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End of Life Choices

Every day in the emergency department I work hard to cure disease and save people's lives. When patients come through the emergency department we start with the assumption that they wish to have all appropriate interventions that could save their lives. Often we are faced with an unresponsive patient, either from illness or trauma, who is unable to convey these wishes, so we aggressively try to keep the patient alive as long as possible.

A couple of months ago I had the opportunity to see a patient who made a different choice. It was the mother of a dear friend of mine who was terminally ill with metastatic cancer. My friend knocked on my door at one a.m. and took me to see his mother, M. "She's not breathing" was all he said.

This was not an unexpected development. I had known that M. was close to death for a couple of days, from conversations with my friend. Her devoted husband had cared for her in their home for over a year, and just a few weeks prior she had made her wishes clear: no more hospitals. The whole family entered the foreign realm of a "hospice" family where they were provided with home nursing care, counseling for the immediate family members, and a variety of services to help them prepare for the inevitable passing of their beloved matriarch. She had been kept comfortable in her home up to this time, with medicine for her nausea, pain, and difficulty sleeping.

I entered the bedroom of my friend's mother and found her lying peacefully with her husband sitting next to her bed, holding her head. According to her wishes, she had passed peacefully in the comfort of her own home. Her husband told me about the past couple of days, and how he had been in constant communication with hospice nurses about how to best care for her and keep her comfortable in her final days. I admired his bravery as he watched his wife of fifty-one years pass, and according to her wishes had not sought medical intervention. It was only now that he wanted my help, to confirm what he and his son knew, M. had died.

Several days ago a seventy eight year old man came to the emergency department unresponsive after a seizure. A CT scan showed that his lung cancer had now spread to his brain. To keep him on the earth we would likely have to put a breathing tube down his airway and put him on a ventilator because he was not able to protect his own airway and therefore unable to exchange oxygen and carbon dioxide. His wife was unaware of his wishes - and it saddened me to see the position she was now in, being asked to decide if her husband would want to be placed on a ventilator knowing that his cancer had spread and he would likely die from his disease. He was unconscious and had not had the opportunity to learn that his cancer had spread, and to make plans for the future.

It is important for people to let a family member know under what circumstances they would not want further medical intervention. There are many important factors that go into this decision and it is different for every person. As a physician, while I am sometimes surprised at the choices people make, I need to know these choices so I can honor them. When people are unable to speak for themselves we turn to those who know them and love them to speak for them, and it is easier for these people when they don't have to guess what interventions their loved one would want.